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Who is filling out this form?
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If other, please list who
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How did you hear about us?
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If referral, please list who
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If other, please explain
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Primary Care Provider
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Name
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City and State
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Medical History - Please list all active medical conditions
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Condition
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When did it begin?
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Condition
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When did it begin?
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Condition
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When did it begin?
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Condition
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When did it begin?
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Condition
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When did it begin?
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Additional Notes
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Medical History - Please list any significant resolved medical conditions
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Condition
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When was it resolved?
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Condition
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When was it resolved?
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Condition
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When was it resolved?
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Condition
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When was it resolved?
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Condition
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When was it resolved?
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Additional Notes
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Surgical History - Please list all surgeries
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Surgery
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Date of Surgery
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Surgery
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Date of Surgery
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Surgery
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Date of Surgery
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Surgery
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Date of Surgery
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Surgery
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Date of Surgery
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Additional Notes
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Major traumas and/or accidents
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Trauma
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Date of Trauma
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Trauma
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Date of Trauma
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Trauma
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Date of Trauma
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Trauma
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Date of Trauma
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Trauma
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Date of Trauma
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Additional Notes
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Medications - Please list any medications you take routinely, prescribed or over the counter
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Medication
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Dose/Frequency
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Medication
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Dose/Frequency
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Medication
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Dose/Frequency
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Medication
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Dose/Frequency
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Medication
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Dose/Frequency
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Additional Notes
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Supplements - Please list any supplements/herbs you take routinely
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Supplement/Herb
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Dose/Frequency
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Supplement/Herb
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Dose/Frequency
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Supplement/Herb
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Dose/Frequency
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Supplement/Herb
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Dose/Frequency
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Supplement/Herb
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Dose/Frequency
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Additional Notes
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Allergies - Please list any known allergies and/or sensitivities (medications, latex, foods, etc.)
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Allergy
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Allergy
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Allergy
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Allergy
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Allergy
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Allergy
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Additional Notes
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Occupational History:
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Do you work?
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If no, select the reason
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Occupation (if working or worked previously)
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Lifestyle & Nutritional Habits
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Do you smoke cigarettes?
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If so, how many packs a day?
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At what age did you start?
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If applicable, at what age did you stop?
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Do you drink alcohol?
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If so, how many drinks a day/week/month?
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At what age did you start?
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If applicable, at what age did you stop?
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Do you use any recreational drugs?
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If so, what kind and how much daily/weekly/monthly?
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At what age did you start?
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If applicable, at what age did you stop?
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Servings of soda do you drink per week?
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Servings of coffee do you drink per week?
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Do you have, or have had suicidal thoughts?
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Daily Habits:On average
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Hours of television do you watch per day?
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Hours per day you use computer/work from home
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Hours per day you ride in a car /other vehicle
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Do you exercise?
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If yes above, how often do you exercise?
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On average, how long do your workouts last?
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What are your exercise activities?
• • •
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Comments
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How many glasses of water do you drink per day?
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How many hours of sleep do you get per night?
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Family Health History
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Is your maternal grandmother still living?
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If deceased, please list of what cause and at what age
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Is your maternal grandfather still living?
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If deceased, please list of what cause and at what age
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Is your paternal grandmother still living?
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If deceased, please list of what cause and at what age
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Is your paternal grandfather still living?
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If deceased, please list of what cause and at what age
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Is your mother still living?
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If deceased, please list of what cause and at what age
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Is your father still living?
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If deceased, please list of what cause and at what age
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Is your brother/sister still living?
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If deceased, please list of what cause and at what age
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Is your brother/sister still living?
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If deceased, please list of what cause and at what age
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Is your brother/sister still living?
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If deceased, please list of what cause and at what age
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Family history of diabetes?
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Include family member
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Family history of cancer?
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Include family member
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Family history of heart problems?
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Include family member
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Family history of vascular problems?
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Include family member
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Family history of kidney problems?
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Include family member
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Family history of muscle diseases (myopathies)?
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Include family member
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Family history of movement disorders?
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Include family member
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Family history of gastrointestinal problems?
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Include family member
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Family history of nerve diseases (neuropathies)?
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Include family member
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Family history of autoimmune conditions?
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Include family member
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Family history of neurological conditions?
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Include family member
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Family history of respiratory conditions?
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Include family member
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Family history of psychiatric conditions?
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Include family member
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Family history of musculoskeletal conditions?
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Include family member
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Family history of movement disorders?
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Include family member
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Family history of headaches?
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Include family member
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Other Family history
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Include family member
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Family member have a condition similar to yours
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If yes, please explain:
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Review of Systems - Have you had or have any of the following conditions
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General
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Consistent Fainting
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Chills
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Convulsions
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Depression
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Dizziness
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Weight Loss
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Fatigue
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Fever
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Headaches
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Loss of Sleep
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Weight Gain
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Nerve Pain
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Night Sweats
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Excessive Thirst
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Wheezing
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Nervousness
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Autoimmune Disorder
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Lyme's Disease
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Cancer
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Diabetes
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Mumps
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Rheumatic Fever
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Whooping Cough
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Measles
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AIDS/HIV Positive
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Venereal Infection
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Tuberculosis
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Gastro-Intestinal
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Constipation
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Diarrhea
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Ulcers
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Gall Bladder Issues
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Hemmorrhoids
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Liver Problems
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Nausea
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Digestive Complaints
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Stomach Pain
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Poor Appetite
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Rectal Bleeding
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Vomiting
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Vomiting Blood
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Jaundice
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Eye/Ear/Nose/Throat
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Glasses/Contacts
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Sore Throat
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Tonsillitis
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Blurry Vision
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Glaucoma
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Earache
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Hearing Noises (Tinnitus)
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Hearing Noises (Voices)
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Light Sensitivity
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Sound Sensitivity
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Smell Sensitivity
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Enlarged Thyroid/ Goiter
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Crossed Eyes/ Strabismus
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Double Vision
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Ear Discharge
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Nasal Obstruction
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Nose Bleeds
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Worsening Vision
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Eye Pain
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Deafness
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Hay Fever
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Sinusitis
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Hoarseness
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Changes in sense of smell
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New Single Select
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Respiratory
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Asthma
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Emphysema
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Chronic Cough
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Chest Pain
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Difficulty taking normal breath
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Difficulty taking deep breath
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Wheezing
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Heaviness in Chest
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Coughing Blood
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Coughing Phlegm
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Pleurisy
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Pneumonia
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Musculoskeletal
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Arthrtis
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Gout
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Artificial Joint
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Osteoporosis
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Backache
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Foot Pain
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Broken Bones
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Dislocations
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Pain Between Shoulder Blades
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Painful Tailbone
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Neck Stiffness
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Spinal Curvature
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Loss of Range of Motion
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Weakness
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Change in Musce Tone
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Muscle Twitching
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Tremors
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Swollen Joints
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Changes in Gait
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Dystonia
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Chorea
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Myoclonus
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Cardio-Vascular
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Ankle Swelling
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Anemia
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Angina
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Heart Murmur
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Artificial Heart Valve
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Blood Disorder
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Congenital Heart Disorder
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Excessive Bleeding
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Poor Circulation
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High Blood Pressure
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Low Blood Pressure
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Heart Fluttering/Palpitatons
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Rapid Heartbeat
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Slow Heartbeat
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Pain Over Heart
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Venous Insufficiency
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High Cholesterol
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Skin
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Dryness
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Bruise Easily
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Hives
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Itching
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Eczema
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Sensitive Skin
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Skin Discoloration
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Thinning of Skin
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Boils/Carbuncles
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Psoriasis
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Melanoma
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Neurological
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Epilepsy
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Head Injuries
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Knocked Unconscious
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Spinal Tap or Injections
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Alzheimer's Disease
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Attention Problems
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Mental Fogginess
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Mental Fatigue
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Mood Changes
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Lack of Motivation
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Incoordinaton
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Lapses in Memory
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Difficulty with word retrieval
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Difficulty remembering names
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Difficulty remembering faces
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Difficulty expressing feelings
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Difficulty recalling memories
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Difficulty recalling memories
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Difficulty understanding directions
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Difficulty with simple math calculatons
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Difficulty with comprehension
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Difficulty finishing tasks
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Abnormal Sensations
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Uncontrolable Movements
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Increased Anxiety or Panic
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Increased sensitivty to light
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Increased sensitivity to touch
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Increased sensitivity to sound
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Easily get annoyed/frustrated
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Dyslexia
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ADHD
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Autism Spectrum Disorder
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Psychological
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Depression
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Anxiety
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Suicidal Thoughts
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Addiction
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Dipolar Disorder
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Easily Agitated
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Schizophrenia
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Abnormal Mood Swings
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